“The evidence from the nursing staff that a patient would not be supervised within the…”
Dated 11 Oct 2017, from the coroner for Blackburn, Hyndburn and Ribble Valley. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 6 Dec 2017. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated11 Oct 2017
- Deadline6 Dec 2017
- Published on judiciary.uk27 Nov 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Lancashire Hospitals NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Dec 2017. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. The evidence from the nursing staff that a patient would not be supervised within the toilet unless there had been a fall on the ward. It was not clear whether this was a general understanding by nursing staff or a specific policy. I am concerned that future falls (and therefore deaths) will occur unless action is taken to address this policy/understanding. 2. The evidence from the clinicians was that there were sometimes difficulties in transferring images to other hospitals. In this case there appeared to be misunderstandings as to whether or not Wrightington could access radiology images/reports through the Royal Blackburn Hospital PACS system and viceversa. In the present case this caused delays in the commencement of necessary physiotherapy treatment and I am concerned that future delays could similarly delay treatment and risk future deaths as a result. 3. During the course of evidence it became apparent that the Radiology department at the Royal Blackburn Hospital had refused to carry out Judet Xrays as specifically requested by the orthopaedic specialists at Wrightington. This caused delays in commencing partial weight bearing physiotherapy in Mr Clifford’s case. I am concerned that future delays could similarly delay treatment and risk future deaths as a result.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2017-0291
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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